In this belief the great clinical teachers are agreed. Additional evidence pointing to the same conclusion is afforded by the cases in which the cessation of recurrent articular attacks is followed by re current paroxysms of gastric distress which are repeated, sometimes at regular intervals, until they are terminated by the renewal of artic ular manifestations. The acceptance of this doctrine regarding the relation that exists between gout and dyspepsia should not diminish the caution with which the investigation of individual symptoms is approached. In certain cases the disorder of the stomach is the con sequence of renal disease, and is one of the modes of expression by which the occurrence of uraemia is declared. In many instances the exciting cause may be found iu excess of eating and drinking, or in the indigestible quality of the food. But, behind all these exciting causes a careful research will seldom fail to discover an intimate connection with the obscure errors of nutrition that underlie the gouty diathesis.
The rather rarely observed phenomena of retrocedent gout are still regarded with considerable skepticism by many writers. Cer tain traditions are recorded in the standard works, relating the his tories of reckless patients who, in order to assuage their pain, have soaked a gouty foot iu ice-cold water, to the immediate relief of acute inflammation, and an immediate appearance of violent gastral gia, precordial distress, dyspucea, hiccough, vomiting, and collapse. These formidable symptoms are generally dissipated by copious evacuation of the bowels, or by a return of inflammation to the de serted joint. A flood of ink has been shed in the effort to discredit the apparent connection between these consecutive events ; but still it remains impossible to disabuse the mind of the unbiased observer who has witnessed such a case, of the belief that there is something more than a merely accidental connection between these facts of retro cession. Especially convincing are those rare cases in which articular inflammation is interrupted by a gastric crisis, and is resumed again so soon as the stomach is relieved. The bare fact that after death the gastric mucous membrane exhibits all the signs of acute local inflam mation does not militate against the theory of retrocession, for daily experience and observation show how rapidly a gouty joint develops the evidences of acute inflammation, and the same thing may occur in the stomach. It is true that in certain cases, complicated with renal disease, violent vomiting and collapse may be excited by alT0113 ie intoxi cation; hut these are usually witnessed among the victims of chronic gout, and there is nothing of an acute character in their articular affections. When the stomach exhibits after death the signs of chronic inflammation, they must be accepted, of course, as evidence of chronic gastric disease ; but that need not preclude the idea of an acute attack engrafted upon an old worn-out stem, if the articular disease be suddenly suppressed. The rarity of an event is no proof of its unreality ; retrocedent rheumatic peritonitis, for example, is an uncommon incident, yet it does sometimes occur. In short, while admitting the fact that gastric disorder dependent upon its usual ex citing causes may accidentally concur with an attack of gout, begin fling a little sooner or a little later than the articular crisis, it must still be insisted that there is in the nature of things no reason why retrocession may not occur, and that there is sufficient testimony on the part of trustworthy witnesses to warrant the belief that it does occasionally take place.
The same arguments have been used for and against the existence of intestinal gout. It is not an unusual experience for gouty subjects
to suffer with a catarrhal condition of the intestinal canal without much regard to the character of their diet and mode of life. As in other forms of Catarrhal enteritis, the action of the bowels is very irregular; sometimes constipated, flatulent, and colicky, and again relaxed, with frequently recurrent diarrhoea that continues for several clays and then spontaneously ceases. Sometimes, however, there is persistent and obstinate looseness of the bowels, which continues for many years without pain or noteworthy injury of the general health. It is liable to intermission, and to recurrence in the spring and autumn months. In many instances it is preceded by severe colic, flatulence, headache, and deposit of urates in the sediment of the urine. In these preliminary disorders it bears a close resemblance to the crises of articular gout; and frequently it is clearly alternating with such attacks. The resemblance is further carried out by the relief that is afforded and the improvement of health that is experienced after such evacuations. But when diarrhoea becomes permanent, it, in associa tion with other visceral complications, seems finally to debilitate the chronic sufferer. Among gouty subjects it is frequently remarked that catarrhal inflammations of a migratory character are not uncom mon. In such cases there is often observed an alternation between bronchitis, or asthma, and catarrhal diarrhoea—one form of mucous disease taking the place of another, and all of them related to other diathetic manifestations in a way that seems conclusive as to the community of their cause. Witness such facts as are related by Scudamore, Graves, and other clinical teachers who have noted the effects of exposure to wet and cold during an attack of articular gout—suppression of local symptoms, immediate occurrence of in testinal pain, constipation, hiccough, flatulence, and other evidences of abdominal distress—in a word, retrocedent gout. Sometimes the focus of the disorder is about the head of the colon, in the right iliac fossa, and it has been in certain cases incautiously ascribed to appen dicitis; but usually the pain is unattended by fever, and is relieved by a summary cathartic and a few doses of sodium salicylate. Some times, however, retrocession is accompanied by fever and symptoms of acute inte6tinal inflammation. When this chiefly involves the small intestines there is a copious watery flux like that of cholera morbus. It was an attack of this character that terminated the life of the great Sydenham, on the 29th of December, 1689. When the descending colon and the rectum are affected, the discharges are scanty, slimy, mixed with blood, and attended with tenesmus, like those that occur in genuine dysentery. Severe hemorrhoidal attacks are also commonly associated with the gouty predisposition, and sometimes appear to replace the ordinary articular crises.
Despite these facts, one must not fall into the error of ascribing all cases of diarrhoea or dysentery or intestinal colic in a gouty person to masked or retrocedeut gout. The same caution must be exercised that is demanded in the corresponding forms of gastric disorder. Arthritic patient's may have the same diseases, excited in the same way, that are experienced by other people. It is only when the phe nomena of articular inflammation and intestinal disorder are so inti mately related that they clearly replace one another, and are habit ually interchangeable, that we are justified in claiming the identity of their cause.